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APPLICATION FOR PERMIT 1' Ir SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 'i Telephone (209) 466-6781 '�� F PERMIT EXPIRES 1 YEAR FROM DATE ISSUE[ (Complete in Triplicate) Application is hereby made to the'San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well pump and the Rules and Regulations of the San Joaquin Local Health District. i �y Il3 Job Address ,etc— City Lot Size l5_�1 J&Zm c� �• �, Owner's Name J�I Address Phone Contractor's Name, .':+�� License No. , �3�!"""" r"""""" Phone — '—u 'r TYPE OF WELL/PUMP: II NEW WELL LCL.--•. WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION N---' SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK &-aw —SEWER LINES DISPOSAL FLD. PROP. LINE \ 114 FOUNDATION _t AGRICULTURE WELL OTHER WELL PITS/SUMPS I N _ .M--+ter' INTENDED`USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Industrials Bottom ❑ Manteca Dia. of Well Excavation...— Dia. of Well Casing 1f� I' stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I10 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type € out ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 € i Depths F110--Material,(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ 'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is, I "� available within 200 feet.] Installation will serve. R s deuce_ Commercial__ Other 1` ,*3` Number of living nits: 11 Number of'bedrooms .J Character of soil to a depth of 3 feet: Water table depth i `ASEPTIC TANK ❑ Type/Mfg ` Capacity No. Compartments s PKG. TREATMENT PLT. ❑ Il s Method of Disposal 'r Distance to nearest Well Foundation Property Line LEACHING LINE ❑ No: & Length of lines Total length/size F �i FILTER BED ❑ Distance to nearest: Well` Foundation+ Property Line SEEPAGE PITS ❑ Depth —Size_ Number SUMPS —❑ -Distance to.nearest:, Well, Foundation Property Line DISPOSAL PONDS� ❑l- `• I hereby certify that I have-prepared.tfiis"application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature .{ certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant mpl call f r all required inspections. Complete a ing on reverse side. x Signed Xis/ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date � Area Q Pit o Grout nspection by 'l Date — Final Inspection by Date Additional Comments. li ❑ Stk 466-6781 ❑ Lodi ',369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 :t .i a FEE AMOUNT DUE AMOUNT-REMITTED ~ RECEIVED BY DATE PERMIT'NO. INFO -1 + EH 13-244REV.lel831 �!-0